Prime Minister Hun Sen has called for stronger enforcement of regulations on the promotion and sale of baby formula, linking a decrease in the number of women who breast-feed to an increase in unlawful and misleading advertising that misrepresents milk substitutes and deceives new mothers.
A statement released by the premier ahead of National Nutrition Day, which falls on Friday and will focus on the importance of breastfeeding, instructs health workers, clinics, and formula companies—many of which are flagrantly violating a government ban on promoting baby formula—to adhere to the law.
Mr. Hun Sen pointed to a Ministry of Planning study that found the rate of breast-feeding among children younger than 6 months had fallen from 73.5 percent in 2010 to 65 percent in 2014.
“There are a number of factors that may have contributed to this: lack of knowledge, lack of family support, migrating for employment, short maternity leave, and an increase in advertisements for formula milk as a replacement for breast milk, which cause confusion among the people,” he said in the statement.
“I appeal to all involved parties working on maternal and child health care and nutrition to…monitor and control advertisements of milk substitutes that cause this confusion.”
Visits by reporters to Phnom Penh’s private clinics, pharmacies and baby-goods stores over the past two weeks showed that sub-decree 133, which outlaws the promotion of breast milk substitutes for children younger than 2 years, is being routinely ignored.
Staff at some clinics say representatives of formula companies leave free samples to be passed on to mothers and that staff members oblige despite knowing the potential negative health implications. Some employees also say they have been given gifts, including overseas trips, in exchange for pushing certain brands.
In May, World Vision International and Helen Keller International released a report based on observations made at 66 outlets selling baby formula, not including hospitals and clinics, in six provinces outside Phnom Penh. The findings show that none of the 110 products for sale “fully complied” with advertising and promotional regulations laid out in the government’s sub-decree.
The report, titled “Promotions and Labeling Violations of Baby Formula Companies,” notes that 32 percent of Cambodian children are stunted, and emphasizes the importance of health in the first two years of life, the same age for which breast milk substitutes are intended.
“The high rate of stunting is particularly concerning, given that it is primarily caused by a lack of nutrients during the first 1,000 days of life—from conception to 24 months of age,” it says.
The report concludes that “Violations of [sub-decree 133] are severe and require immediate actions.”
In an email Tuesday, Suong Soksophea, a senior campaign manager at World Vision, said that health care workers and staff at outlets that sell formula were generally unaware of the sub-decree, and that marketing of the products had “increased significantly” in recent years.
The formula companies, she said, “host many workshops/ events that attract parents and introduce them to their products,” and use marketing tactics that “can potentially mislead users.”
According to Ms. Soksophea, in the time since the report was released, the Ministry of Health subsequently created a committee to oversee the enforcement of sub-decree 133, arranged workshops to inform the private sector of their obligations, and then sent out formal warnings to all groups involved in the industry.
Or Vandin, director general of the ministry’s technical department, said Tuesday that sub-decree 133 is strictly enforced and asked a reporter to provide any evidence to the contrary.
“If companies are not compliant with the sub-decree, we will follow the law,” she said, declining to elaborate on any possible punishments.
New mothers spoken to over the past two weeks have given a variety of reasons for deciding to rear their offspring on baby formula. Two of the most prominent were that they were not naturally producing enough milk and that the baby rejected breast milk after having tried formula.
Sophie Goyet, a midwife who specializes in obstetrics and epidemiology, Tuesday offered an explanation of how those particular complaints are both linked and misinformed. Babies will reject the breast after trying the bottle, she said, simply because breast-feeding requires a technique that is learned and sucking from a bottle is much easier.
“That is why, before the baby has learned to latch on to the breast, artificial nipples should be avoided so the baby does not become accustomed to using incorrect sucking patterns,” Dr. Goyet said.
“Offering formula milk or baby bottles to mother just after delivery is really, really bad and should be avoided in most of, if not all, circumstances.”
Some new mothers have also said that despite the ban on in-clinic promotions, they were offered free formula from health workers alongside advice regarding the importance of breast milk—a contradictory practice confirmed by staff at two clinics.
In an email Tuesday, Arnaut Laillou, a nutrition specialist at Unicef Cambodia, said that through aggressive marketing and increased availability, breast milk substitutes had “dislodged breastfeeding as the desirable method for feeding infants” among Cambodians.
Potential profitability in an ever-expanding market, he said, leads formula representatives to twist the truth and “persuade doctors” to give newborns a first taste of formula milk, after which they may never return to the breast.
“It seems that hospitals are an effective entry point for companies,” Mr. Laillou said. “New mothers trust health professionals and tend to stick with brands used in hospitals.”